Calorad - Offline Order Form (Please print, complete and return to us)

 
Billing Info:
Name: _____________________________________
Address: _____________________________________
City, State & Zip: _____________________________________
Country: _____________________________________
Phone Number: _____________________________________
Email Address: _____________________________________
 
Shipping Info:
Name: _____________________________________
Address: _____________________________________
City, State & Zip: _____________________________________
Country: _____________________________________
 
Product Order
QTY
Unit Price
Shipping & Handling
Total
1 Calorad® (1 month supply)  
$55.00
$7.95
 
3 Calorad® (3 month supply)  
$119.95
$9.95
 
5 Calorad® (5 month supply)  
$179.95
$9.95
 
   
 
   

Total Price: 

 


Payment Information: 

___ Credit Card    ___ Money Order    ___ Check (Personal Checks take 2 weeks to process)
 
Credit Card Information:
Visa    MasterCard    Discover    American Express   
Credit Card Number: ________ - ________ - ________ - ________   Exp. Date: _____ / _____
Signature______________________________________

Please mail this form to:

Health10.com, Inc.
226 East Market St.
Suite # 4
York, PA 17403
USA

Or fax it to: 1-253-669-9961

Make checks & money orders payable to - Health10.com, Inc. -

If you have questions, please call us toll free at 1-888-393-9079